DescriptionThe Utilization Management Nurse 2 utilizes clinical nursing skills to support the coordination, documentation and communication of medical services and/or benefit administration determinations. The Utilization Management Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.
The Clinical Access Team (CAT) is a department that facilitates and/or assists members with concurrent clinical access to care issues. On this telephonic team, Clinical Access Team (CAT) Nurse 2 and UM Administration Coordinators provide personalized guidance to members & providers to promote better health outcomes. CAT associates get their work via the inbound call queue or by electronic means and are expected to fully function utilizing either method. The Clinical Access Team (CAT) Nurse 2 serves as a liaison between members, providers, & other stakeholders to help provide timely resolution with clinical access to care needs. CAT promotes Plan compliance with state mandates, regulatory, & accrediting bodies. In this role you will:
- Facilitates resolution to our members’ clinical access to care issues such as obtaining timely appointments and necessary referrals, assisting with durable medical equipment (DME) issues, transfer of medical records, and providing member education regarding plan.
- Assesses the member’s clinical condition for potential referral to clinical programs.
- Is knowledgeable of Humana systems.
- Is expected to manage time effectively in order to meet expectations.
- Is expected to work independently in a work-at-home environment with minimal supervision by the CAT Manager.
- Performs other duties as assigned
- Can choose between an 8 hour, 5 days a week work shift from 9:30-6 p.m. EST OR 10 hour, 4 days a week shift from 7:45 – 6:15 p.m. EST
- RN licensure, active and unrestricted, in the state(s) in which the nurse is required to practice
- Ability to obtain multi-state licensure
- At least 3 -5 years or more of clinical experience; preferably in an acute care, skilled or rehabilitation setting, home health, hospice, DME, triage, utilization, and case management
- Ability to work independently, and within a team
- Ability to multi-task via multiple computer systems, and talk and type at the same time
- Professional verbal and written communication skills
- Minimal travel required
- Must have the ability to provide a high speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10x1 (10mbs download x 1mbs upload) is required
- Bachelor’s degree in nursing (BSN), or related healthcare field
- Home health or hospice experience is highly preferred
- Previous Medicare experience and familiarity with CMS guidelines
- Previous experience in a call center
- Previous case management, utilization review, or triage experience
- Health plan operations experience
- Knowledge of Humana systems and clinical programs
- Bilingual – ability to speak fluently in both English and Spanish
Humana is an organization with careers that change lives—including yours. As an innovator in the fast-paced industry of healthcare, we offer our associates careers that challenge, support and inspire them to use their passion for helping others and to lead their best lives. If you’re ready to help people achieve lifelong well-being, and be a part of an organization that is growing and poised to make an impact on the future of healthcare, Humana has the right opportunity for you.
Scheduled Weekly Hours40